Presentation on
Jaipur Terminal Fire
of 29.10.2009
By
SK Roy, GM(HSE),CO
Indian Oil Corporation Limited
1
Flixborough (1974)
Explosion/
Fire
28 Fatalities,
36 Injuries
Plant virtually
demolished
2
Pasadena October 1989
Explosion/
Fire
23 Fatalities,
132 Injuries
3
Esso Longford
25th September 1998
Explosion/
Fire
2 Fatalities, 8 Injured,
Fire continued
for 2 ½ days
4
Toulouse
21st September 2001
Explosion/
Fire
31 Fatalities,
2442 injuries
Created 50 m dia
crater more than
10 metre deep
5
BP Texas City Refinery
23rd March 2005
Explosion/
Fire
15 fatalities,
over 170 injured
6
Buncefield Depot
11th December 2005
Before
After
7
Jaipur Terminal Fire, India
29th October 2009
Fire Continued
for 11 days
11 fatalities,
Terminal Closed
8
Safety at Jaipur Terminal
9
Fire Scene at Jaipur Terminal
10
Fire on Diesel Tanks
11
Fire on Kerosene Tanks
12
Scenes of Fire
13
Scenes of Fire
14
Kerosene tank & MS tanks(Behind)
15
Scene of Fire
16
View of all 11 tanks
17
Fire on Three MS Tanks
18
Fire on Three MS Tanks
19
Kerosene tanks
20
MS Tank collapsed
21
HSD Tanks on 2rd day
22
Over pressurised Lube oil Drums near tanks in Fire
Many Exploded
23
Near by population on Run
24
Demolished Emergency Response Centre near Gate
25
Control Room & Maint. Building
26
Collapsed car shed in the terminal
27
Terminal Office Building
28
Fire water Pump House
29
Demolished Smoking Booth near Boundary Wall
30
Extent of Damage
31
Tank Truck Loading Gantry
32
Terminal Pumping Station
33
KBPL Pumping Station
34
Ruptured pipelines
35
Maintenance Building near gate
36
Damage to Vehicles
37
Business Continuity Centre
38
Overturned Fire Monitor.
39
Damage at nearby car Showroom
40
Damage at nearby car Showroom
41
Pictorial Depiction of the Incident
42
Plot Plan
EMERGENCY GATE
KEROSENE TANKS
HSD TANKS
MS TANKS
SECURITY
GATE
GENUS
C/R
LUBE
WAREHOUSE
STORE CANTEEN
S/S
F
W
P
H
BCC
PIPELINE INSTALLATION
FW
TANKS
DG
T
T
L
ADMIN
SECURITY
GATE
KBPL P/H
P
H
MS
TANKS
C/R
EXCHANGE PIT
NTS
43
PLT Line up
FROM PIPELINE
DIVISION
OMC
TANK DYKE
INLET LINE
DIP: 11.86 M
DRAIN
VALVE
TANK 401A
DISCHARGE LINE
NTS
44
Schematic Layout
HAMMER BLIND
VALVE
TRANSFER
PUMP -1
11.86 M
MS TANK 401A
MOV
HOV
Standard Operating Sequence
Likely Sequence
1. Ensure MOV and HOV are closed
1. MOV opened first.
2. Reverse the position of Hammer Blind Valve
2. Hammer Blind Valve opened
3. Open the HOV
3. Leakage started.
4.Open MOV (initially inching operation to
establish no leakage from Hammer Blind Valve
body)
NTS
45
Schematic of Valves on Tank Discharge Line
N
A
Tank wall
40 cm
80 cm
MOV
MOV
310 cm
160 cm
160 cm 90 cm
205 cm
PLATFORM
Hammer Blind
Hammer Blind
10”
12”
90cm
HOV
HOV
PLT/TLF
P/L
MS
Tank
A
NTS
46
Source of MS Leak
47
MOV on Discharge Line
48
Hammer Blind and HOV on Discharge Line
49
Source of MS Leak
50
Vapour Cloud Explosion (VCE)
 Explosion occurred to the tune of approximately 20
Tons of TNT.
 Nine of the total 11 tanks caught fire immediately after
first explosion. Balance two tanks(at a distance) caught
fire after some time.
 Decision was taken to allow the fuel(60,000 KL) to burn
as all fixed fire fighting facilities at the location got
demolished.
51
Vapour Cloud Explosion (VCE)
 Building in the immediate neibourhood of the terminal
were heavily damaged.
 Minor damages & window pane breakage occurred
upto 2 KM distance from the facility.
 Total loss due to fire & explosion including loss of
product, stores, fixed assets, compensation for third
party losses were approximately $ 60 million.
52
The Incident – Major Timelines
S. No.
Activity
Time
(Hours)
Before
1750
1.
Sealing of tank lines, valves etc. for PLT
2.
Tank handing over by Pipelines to Marketing
1750
3.
Start of hammer blind reversal work
After
1750
4.
Start of MS spillage
1810
5.
Rescue of Operation Officer
6.
First communication outside the terminal
7.
Sounding of siren
8.
Formation of vapour cloud across the terminal
9.
Vapour Cloud Explosion
1820-1824
1824
After
1830
1810-1930
1930
53
The Incident – Possible Scenarios
Scenario-I
 MOV was in open condition before the start of hammer
blind reversal job

Opened by someone anytime between the previous blinding
operation and 29.10.2009.
Not possible to establish any one of the above conclusively
54
The Incident – Possible Scenarios
Scenario-II
 MOV opened accidentally when the blind was being
reversed (due to spurious signal or manually).
Amongst the two Scenarios, Scenarios-I, that the MOV was in
open condition before the start of the hammer blind reversal job,
appear to be more likely.
55
Source of Ignition
 As Vapour Cloud spread in such a large area , the
source of fire can be anything inside or outside the
installation.
 The Non flame proof electrical fittings in administration
block
located in the south western direction of the
terminal or Spark during starting of the vehicle at the
installation are probable cause of source of fire.
56
The Incident – Contributing Factors
 Non-availability of one of the shift workman, who was
supposed to be on duty.
 Control room remaining unmanned due to above.
 Absence of specific written-down procedures for the
works to be undertaken and, therefore, reliance on
practices.
57
The Incident – Contributing Factors
 Opening of the HOV before completion of hammer
blind reversal operation.
 Not checking the MOV for its open/close status and
not locking it in Closed position.
 Not
using
proper
protective
attempting rescue work.
58
equipment
while
The Incident – Contributing Factors
 Initiation of the critical activity after normal working
hours, leading to delay in response to the situation.
 Non-availability of second alternate emergency exit.
 Proximity
of
industries,
institutes,
complexes etc. close to the boundary wall.
59
residential
Accident Investigation

Ministry of Petroleum & Natural Gas, Govt. of India
constituted an independent seven member committee headed
by Sh. MB Lal , Ex. Chairman, HPCL to enquire into the
Incident.

MB Lal committee submitted their report on 29.01.2009 &
made following observation:
“The Jaipur incident was first of its kind in India & the third
one reported globally.”
60
Accident Investigation

MB Lal committee made following conclusions on cause:

The Loss of containment in terms of time & quantity was never
considered a credible event and accordingly not taken into hazard
identification.
 Basic operating procedures for hammer blind opening was not
followed.
 Accident could have been managed if safety measures provided in
control room were not made defunct.
 Backup for emergency shutdown from Control room not
available.
 There was delay in emergency response for long period.
61
Accident Recommendations

MB Lal committee made 118 recommendation to be
implemented at Oil installations.

MoP&NG constituted a Joint Implementation Committee
(JIC) comprising of :
a) Head of Corporate HSE of IOCL,BPCL & HPCL.
b) ED(O),IOCL; ED(O&D),HPCL & ED(logistics),BPCL
b) Director (M), OISD
ED(HSE),IOCL was made convener of the JIC.
62
Accident Recommendations
JIC segregated 118 recommendations into various
categories for ease of implementation viz :

- Engineering related
- Operation related
- Procurement related
- Training related
- Policy related
- OISD related
- Ministry related
63
Recommendations- Engineering Related

Only a closed system design should be adopted. All
Hammer Blind valves should be replaced with
Pressure Balancing type Plug Valves / Ball Valves.

The first body valve on the tank should be Remote
Operated Shut Off Valve (ROSOV) on the tank
nozzle inside the dyke with Remote Operation from
outside the dyke as well as from the control room.
ROSOV should be fail safe and fire safe.
64
Recommendations- Engineering Related

Adequate lighting should be provided in operating
areas. Minimum Lighting lux level should be as:
Tank farm area/Roads – 20
Main operating area/pipe racks - 60
Pump house/sheds/switches – 100

For floating roof tanks, roof drain to be of more
robust design to prevent oil coming out when roof
drain is open for water draining operation.
65
Recommendations- Engineering Related

Piping design inside tank dyke area should ensure
easy accessibility for any operations inside dyke in
the tank farm.

Tank Dyke Valves should be provided with position
indicator (open or close) in control room and
necessary hardware and instrumentation should be
provided for this.
66
Recommendations- Engineering Related

Wherever Pipeline transfers take place, Mass Flow
Meter with Integrator should be provided on
delivery pipelines.

The Tank Farm Management system(TFMS) should
be upgraded and integrated with SAP and provision
for recording of all critical events in SAP as well as
TFMS (such as critical valves position, start/stop of
pumps, levels in tanks, alarms etc).
67
Recommendations- Engineering Related

High level alarm from the radar gauge and high
level alarm from a separate tap off should be
provided.

Buildings
not
related
including canteen
to
terminal
operation
should be located outside the
plant area.
68
Recommendations- Engineering Related

Locate buildings and structures in the upwind
direction (for the majority of the year) as far as
practicable.

Control Room, Fire water tank and fire water pump
house should be located far away from potential
leak sources/tankage area.
69
Recommendations- Engineering Related

Automation of
sophisticated
Tankfarms and terminals with
systems
both
in
hardware
and
software.

The emergency exit gate should be away from the
main gate and always be available for use for
personnel evacuation during emergency.
70
Recommendations- Operation Related

Site
specific,
Standard
Operating
Procedures
(SOPs) should be prepared which not only give
what the procedures are, but also why they are
needed.

The critical operating steps should be displayed on
the board near the location where applicable.
71
Recommendations- Operation Related

Management
of
change
procedure
should
be
immediately implemented.

Mock drill whenever conducted should include the
full shutdown system activation also.
72
Recommendations- Operation Related

Emergency procedures should be written and
available
to
all
personnel
in
the
installation
outlining the actions to be taken by each during a
major incident.

Carry out HAZOP Study and Quantitative Risk
Assessment (QRA) on large sized installations
through well qualified agency .
73
Recommendations- Operation Related

All personnel working at the terminal should be
given simulated live fire fighting training through
reputed training institutes.

Shift manning should always be maintained
74
Recommendations- Fire Protection Related

Remote operated long range foam monitors (1000 GPM
and above) to fight tank fires shall be provided which
should be of variable flow.

The Rim Seal fire detection and protection system
shall be installed in all Class ‘A’ products in the
terminal.

Medium expansion foam generators shall be
provided to arrest vapour cloud formation from
spilled volatile hydrocarbons.
75
Recommendations- Fire Protection Related

The fire water requirement for terminals shall be
based on two fire contingencies simultaneously as
is the case in Refineries.

An emergency kit consisting of safety items viz. fire
suites, various leak plugging gadgets, oil
dispersants and oil adsorbents, lifting jacks (for
rescue of trapped workers), high intensity
intrinsically safe search lights for hazardous area,
etc. and should be readily available at the
terminals.
76
Recommendations- Fire Protection Related

Wherever there is a cluster of terminals of different
companies,
an emergency response
centre
equipped with advanced firefighting equipment viz.
fire tenders and trained manpower shall be
considered on cost sharing basis .
77
Recommendations- Fire Prevention Related

CCTV’s should be installed covering tank farm areas
and other critical areas. The CCTV should be
provided with an alarm to provide warning in case
of deviation from any normal situation.

Hydrocarbon (HC) detectors should be installed
near all potential leak sources of class ‘A’ petroleum
products e.g. tank dykes, tank manifolds etc.

VHF(Wireless Hand sets) handsets should
provided to each of the operating crew.
78
be
Recommendations- Policy Related

Corporate HSE department should be strengthened
& should directly report to CEO.

Performance evaluation of Company employees
should have Minimum 20% weight-age towards
safety.

Annual safety audits should be done by a qualified
third party agency.
79
Recommendations- Present status
Total Recommnendations : 113
Recommendations implemented : 33 (30%)
Pending Recommendations :
•Recommendation under review
•Engineering related
•Operations Related
•Procurement related
•Training Related
•General/ Policy related
•OISD Related
80
: 01 (01%)
: 19 (17%)
: 06 (05%)
: 08(07%)
: 06(05%)
: 24(21%)
: 16(14%)
Any Question ?
81
Thank You
82